ORIGINAL RESEARCH

 

Childcare and children's healthcare: historical factors and challenges

 

 

Renata Cavalcante Kuhn dos Santos^I; Rosa Resegue^II; Rosana Fiorini Puccini^III

^IPediatra, preceptora do Programa de Residência Médica em Pediatria do Departamento de Pediatria. Escola Paulista de Medicina - UNIFESP
^IIPediatrician in the Discipline of General and Community Pediatrics, Department of Pediatrics, Escola Paulista de Medicina, UNIFESP. PhD in Sciences from UNIFESP. Coordinator of the "Develop" Project (Health Department of Embu and UNIFESP)
^IIITitular Professor of the Discipline of General and Community Pediatrics, Department of Pediatrics, Escola Paulista de Medicina, UNIFESP

Corresponding author

 

 

---

ABSTRACT

This paper reviews the history of puericulture and attention to children's health in Brazil and establishes relationships between this history and the concept of childhood at different times and within different sociocultural contexts, and between this history and the way in which the Brazilian healthcare system has been organized. The characteristics of the Brazilian educational process, the state's role in healthcare, the creation of the national health system and the creation of the children's and adolescent's laws are highlighted as determinants of healthcare that consider children and their families as subjects under the law. These important achievements within Brazilian society have stimulated changes in clinical practice and, especially, in childcare. Today, the state no longer has a controlling role over families' childcare through regulation of individuals' conduct. Rather, childcare is undertaken scientifically, through a multiprofessional team in partnership with families and communities.

Key words: childcare; right to health; patient rights; health systems; social history of children.

---

 

 

INTRODUCTION

The history of childcare and children's healthcare forms part of the processes of organizing the healthcare system, and is also related to the concept of childhood and to children's role in families and society within different cultural and historical contexts¹. Different ideological concepts all maintain that this history is continually under construction and that it takes in a diversity of paths and sources of information: documents from government bodies, demographic data, texts and studies within the field of human sciences, and important contributions from art, music and literature. Thus, understanding the process of structuring and organizing childcare and children's healthcare requires a contextualized approach that bears in mind that ideas and expectations relating to children are also constituents of the subject under formation².

Áries (1981)³ is one of the authors who has made a large contribution towards comprehending the historical nature of the concept of childhood. Even though his approach was centered on historical singularity rather than totality, which has been criticized by other authors, his influence on demystifying abstract natural children is undeniable⁴. Áries (1981) stated that in medieval society, there was no perception of the particular nature of childhood, although this did not imply any lack of affection for children. In those days, when mortality rates were so high, children's main role was to survive. After succeeding in this stage, they moved directly to living with all of society's adults, and they gained knowledge and learned values through living with adults. The main aims of medieval families were to preserve assets, learn a trade and protect honor and life, at a time when, separately, individuals would not survive. Children's affective and social exchanges were thus conducted in the neighborhood, with their masters, servants, adults in general and other children³.

The modern concept of childhood only emerged in the 18^th century, as a consequence of changes that had occurred in working relations, family organization and children's place in society⁴. At that time, families became more private, by withdrawing into homes that were better prepared for intimacy. Affection became an important factor in the partnership between spouses and came to be expressed between parents and children, especially through care and pampering of small children³.

The era of enlightenment, with its inventions, new techniques and scientific advances, brought questioning of man's role in society and the world. Men began to trust their capacity to be rational, thereby exalting science and placing hope in technology, with instruments capable of mastering nature. Through reason, men would have access to truth and happiness⁵. In this historical and social context, discipline, education, schooling and concern for children's future took on great importance, even though this process was initially limited to bourgeois or noble families. Modern society has thus taken a paradoxical path. On the one hand, children have become objects of attention and have started to be recognized for their particular features but, on the other hand, this attention is based on denial of their own childhood, through considering them to be future adults or "tomorrow's men". This starts from the premise that children are imperfect and immature and that childhood is a passage that needs to be accelerated². In this process, learning that had taken place within the community's day-to-day life started to take place within families and in schools. Thus, the two modern attributes of childhood (innocence and imperfection) form a concept that depends on the history of the subject's existence, his social class or his culture. This concept emerged in urban industrial societies through organization of bourgeois families and through new forms of work, work relations, wealth creation and knowledge generation⁶.

In Brazil, the history of children was strongly influenced by colonial domination⁷, which began in the 16^th century and presented particular characteristics, according to the specific features of how the Brazilian people and their history were formed. The studies of Darcy Ribeiro (2001)⁸ emphasized the complexity of this process, characterized by intense ethnic and cultural confluence: Portuguese settlers, Amerindians who were already here (decimated after a few decades), black African slaves and immigrants from all parts of the world in the 19^th and 20^th centuries. According to Darcy Ribeiro, this new people [as this author put it] became organized along the lines of a model for society that despite establishing different compositions and high degrees of miscegenation, maintained and exacerbated large distances between social classes, which were more significant than racial differences. The 20^th century, especially, was marked by great political, economic, social and demographic changes: urbanization of the population, reduction of illiteracy, reduction of the birth rate, significant increases in life expectancy at birth and great changes to the causes of morbidity and mortality. Expansion of access to healthcare services is considered to be one of the most important determinants for favorable evolution of these indicators⁹.

Care for children and adolescents: childcare and pediatrics

Although scientific interest in children only began in Western countries in the 18^th century, such practices can be recognized as early as the prehistoric era, mainly relating to observation and clinical skills¹⁰. Because children's skeletons are semi-cartilaginous, samples from that time are rare and written records are the main source of information for these studies. Children were mentioned frequently in Mesopotamian medicine and, from this epoch, letters from one physician to another, containing special recommendations for treating them, have been found. Most of these references involved magic treatments, potions and ancient pharmacological measures, with documents suggesting different dosages for children of different sizes. Hieroglyphs indicate possible differentiations between infants, children and adolescents.

During the Greco-Roman period, Hippocrates, Celsus, Soranus and Galen were the greatest contributors towards studies on children. Hippocrates described his observations on certain children's diseases, such as diphtheria, tuberculosis, Pott's disease, febrile convulsions, epilepsy and helminthic diseases. In turn, Aristotle described the physiological elimination of meconium, the transition from colostrum to milk and changes in physical appearance over the course of childhood. The Roman Cornelius Celsus wrote: "Children need to be treated totally differently from adults". Soranus dedicated himself to studies on newborns, and Galen provided better knowledge of child nutrition. During the medieval period, Islamic physicians wrote about child hygiene, exercise, diet and sleep. Sixteenth-century authors expanded the thinking within pediatrics and contributed the concept that children form part of a group requiring different treatment¹⁰.

The 17^th and 18^th centuries were important milestones in relation to recognition of the need for special care for children, in a more systematized and conceptually elaborate manner. This period is also significant in that the state now started to have a role in healthcare. Social demands were not just those of bourgeois interests, but also those of the manual working class, given that the industrial revolution had contributed towards growing urban concentration. Epidemics and unhealthy living conditions in cities triggered actions by the state, which could count on support and interest from the elite, which saw itself threatened by the spread of disease. Individual and voluntary solutions were no longer sufficient to contain such extensive problems. Advances within bacteriology during this period would provide scientific backing, thus further reinforcing the need for measures to be taken by the state¹¹.

The possibility of avoiding diseases though environmental and personal hygiene measures was important not only for the development of childcare but also especially for the concept of state action relating to people's health: the medical police in Germany, social medicine in France and poor-law medicine in England constituted mileposts within this period. The first of these, in Germany, developed especially at the start of the 18^th century, and was characterized by standardization of medical practices and knowledge, subordination of medical practice to a higher administrative authority (the state) and integration of many physicians into a state medical organization. Through the Poor Law, poor people in England started to receive care and attention for their health needs, while the wealthy classes or their representatives ensured their own protection. With the development of urban structures and fear of their consequences, urban medicine emerged in France, marked by sanitary policies and control over individuals' circulation^12,13.

In the light of this movement that became established in the 19^th century, physicians contributed actively when supplying personal or official statistics, by warning about child mortality and inadequacy of working conditions for women and children. Pediatrics started to develop as a medical specialty, accompanying the evolution of other specialties such as obstetrics, gynecology and psychiatry, thus linking clinical practice to teaching and scientific investigation of physiopathological phenomena relating to children. The first published works on childhood diseases started to appear, particularly those relating to feeding and wet-nursing. International events and congresses covered topics relating to clinical pediatrics and also to social factors and their consequences for children's health^14,15.

In France, pediatrics developed notably during this period, both in relation to its clinical and surgical aspects and in relation to its preventive aspects, thus constituting the basis for childcare. The French term for childcare, "puériculture", was coined in 1762 and became consolidated through creation of outpatient clinics for healthy infants¹³. The "Pasteur revolution" provided childcare with a theoretical framework, through redefining the etiology of diseases, extracting the concept of the infection-immunity relationship and incorporating the foundations of antisepsis techniques. This revolution reorganized many aspects of medical knowledge, such as the nutritional needs of the human organism, the physiology of digestion, general care needed to avoid food contamination and infectious diseases and their vaccines. These topics became rules that would define the best way of treating children during their first years of life¹⁴.

For a long time, childcare discourse did not recognize social and cultural diversity and simply reproduced the standards of closed pronouncements, accepting a single method as the correct way to educate children from a mental, psychological and emotional point of view^14,15. Incorporation of childcare as part of the set of public health actions aimed towards children and the role that childcare has as a state control over family and as a standardizer of people's conduct are topics that have been dealt with by many authors. It is clear that there is not just a single way of analyzing the factors that have contributed towards the emergence of childcare and its incorporation into pediatric practice. Children and adolescents nowadays present new healthcare needs and requirements. Today, childcare has a scientific nature, has ceased to be strictly medical and has come to be undertaken by a multiprofessional team, in partnership with families and communities¹⁶.

Attention to children and adolescents in Brazil

Pediatrics was formally constituted as a specialty in Brazil in 1882. Carlos Arthur Morcovo de Figueiredo proposed the first course on this specialty and proposed that a chair of clinical medicine for children's ailments should be created in the School of Medicine of Rio de Janeiro. In his justification for creating this chair, submitted to the imperial government, he highlighted: "The excessive frequency of ailments that afflict childhood, their high lethality and, lastly, the particular features that such ailments present demonstrate the pressing need to provide a large amount of special care for sick children; care that in turn requires knowledge that physicians can only possess if they have dedicated themselves to studying childhood pathology, which is a difficult task"¹⁷ (p. 103). Another justification presented by Moncorvo de Figueiredo to the imperial government made reference to the worldwide trend towards instituting clinics for specific outpatient attendance for children, and also emphasized the most recent knowledge about children's diseases¹⁷. At that time, large numbers of Brazilian physicians undertook complementary training in Europe, where medical practices were strongly directed towards hygiene and control, and childcare was rapidly disseminated¹⁴. Childcare was defined by Martagão Gesteira as "a part of the medical sciences that is concerned with cultivating children's lives and health, by making efforts that allow them to arrive in the world healthy and strong, with normal development, and through supporting and defending them against the many dangers that threaten them, consequent to the malevolent action of environmental and social factors", and was declared to be the main weapon defending childhood^14,15.

Brazilian congresses on hygiene that were held in the 1920s indicated that child mortality was a serious public health problem and that infant nutrition and hygiene were the main factors responsible for this situation¹⁸. At that time, actions aimed towards children that were implemented by the state largely reflected the demands of society and working-class movements of the beginning of the 20^th century¹⁹. Proposals for controlling child labor and granting maternity leave of one month at the end of pregnancy and after delivery emerged. In 1923, Carlos Chagas sought to expand healthcare provision by the federal government through creating the National Department of Public Health and, among other measures, establishing the duties of the Infant Hygiene Inspectorate: special prophylactic measures for transmissible diseases that are specific to the early years of life; guidance and publicity regarding appropriate diets for early and later infancy, under healthy and sick conditions; and inspection of private schools, colleges, orphanages and daycare centers¹⁴. It was thus defined that the state should perform a role of child protection, regarding physical integrity, surveillance, medical care, social assistance and sanitary education. Also in 1923, decree no. 16,300 instituted Children's Festival Day (October 12). In 1925, decree no. 4,983 established complementary measures for the care and protection laws relating to abandoned and delinquent minors.

During the era of the "Estado Novo" (New State), the National Children's Department was created (1940) and, paradoxically, considering the political centralization of that period, the proposal of this department implied active participation by society, especially among physicians, teachers, public authorities and women²⁰. Until the beginning of the 1950s, childcare continued to have standardizing characteristics and was aimed especially towards urban environments, which were progressively taking on greater importance because of industrial development. Subsequently, there was a major expansion of social security-based medicine, based on the private hospital structure. During this period, hospitals took up a central position in healthcare provision, defined as the place where a diversity of medical specialties could be found²¹. The emergence of mother-child programs in the 1970s was one of the attempts to rationalize and implement social policies that would in some way respond to popular healthcare movements²². The crisis on the social security sector that resulted from the model adopted, together with the movements towards redemocratization demanded some responses. In 1978, the Alma-Ata Declaration (WHO, 1978)²³ chose primary healthcare as the strategy for planning, operating and scheduling healthcare services towards the target of Health for All in 2000, and this came to have a strong influence on healthcare policies in many countries, including Brazil.

In the 1980s, through primary healthcare actions towards comprehensive children's healthcare, standards were defined and development of primary healthcare actions aimed towards children were prioritized: follow-up of growth and development, breastfeeding, control over diarrheal diseases, control over acute respiratory infections and control over diseases that could be prevented through immunization. These were considered to be the core elements of the care to be provided within the Brazilian primary healthcare network. The sanitary reform movement and the redemocratization of the country, among other factors, gave rise to changes in the healthcare system that took concrete shape through the creation of the Brazilian national healthcare system (Sistema Único de Saúde, SUS), in 1988 (Brazil, 1988)²⁴. This was done under the maxim "healthcare is a citizen's right and the state's duty", which is one of the most important achievements of Brazilian society.

Although the principles of SUS (equity, universal access to all levels of care, comprehensiveness of actions and social control) are present in legislation, continual watchfulness regarding qualification of these principles is required. Within pediatric care, there are additional rights guaranteed through the Children and Adolescents' Statute²⁵, thereby defining the state's role and responsibilities relating to care for children and adolescents. Through this statute, children have become subjects under the law for the first time in Brazilian history.

Childcare today: rights and autonomy

Through gaining knowledge about the origins of childcare, the authoritarian and disciplinary manner in which it was introduced into pediatrics can be seen. However, important changes have continually been implemented, with the aim of incorporating aspects of societal organization, care models and social rights. Reflection on the concepts of health, disease, life, death and autonomy is fundamental within this field, with the understanding that such knowledge is complementary to biomedicine and that no position of neutrality and objectivity that neglects the sociocultural dimensions that are also present in the therapeutic process can be taken up. With the shift from subjectivity to objectivity, and from respect for values to setting "neutral" rules and standards, a gulf has grown between physicians and patients, and between patients and their bodies. In this manner, patients' capacity for action as subjects in the healthcare process has diminished²⁶.

With the aim of restoring values such as democracy, ethics, critical capacity and autonomy in medicine, some proposals have been emerging more recently. Medicine today, including pediatrics, should prioritize the feelings and values of patients, their families and healthcare professionals, who are all subjects involved in restoration of health, in a shared manner. Reflection conducted jointly in order to make the necessary decisions should be stimulated, i.e. democratization of the physician-patient relationship. Puccini and Cecílio (2004)²⁷ considered that from this transformative perspective, "the relationship between healthcare professionals and users gains importance: moving from a relational environment of individualisms alongside other individualisms to a relational environment of social subjects alongside other social subjects. Within the field of healthcare, the perspective of social achievement of the right to healthcare constitutes a search for a more advanced stage of autonomy, defined as people's capacity not only to select and assess information with a view to action, but also to criticize and, if necessary, to change the rules and practices of the society to which they belong".

The new Medical Ethics Code²⁸ establishes the autonomy of patients and their families, in several of its articles, and it emphasizes their right to information about their own health and treatment decisions. In the state of São Paulo, law no. 10,241, promulgated on March 17, 1999, guarantees that citizens shall be afforded dignity when attended, with identification by name, protection of personal data, mandatory identification of the healthcare professional and access to medical files. It also establishes patients' fundamental right to receive clarifications about the characteristics of their disease and, with such information, to consent or refuse to undergo diagnostic and therapeutic procedures, in a free and voluntary manner²⁹.

This long process of changes reveals the complexity of the factors involved and their relationship with issues involving society as a whole. The legislation has always resulted from wide-ranging debate that has involved diverse interests and concepts that differed regarding their coverage of social rights. Recognition of specificity in pediatric practice and organization of child and adolescent-centered healthcare constitute linked processes that have had a strong relationship with the history, culture and politics of different societies. A critical look at the history of childcare, in turn, has led to greater comprehension of its limitations in day-to-day practice. Understanding that childcare is not constituted by "universal scientific truths", but by standards conceived at different historical times and through a variety of interests, may help pediatricians to find less authoritarian and less rigid ways of transmitting their practices, starting from the process of making medical decisions on the concrete realities of families. In reflecting on children's relationship with healthcare professionals, they have to be taken to be singular and individual, but cannot be considered outside of the society, family and culture to which they belong.

Lastly, it needs to be recognized that there is a need for transformation regarding the concept of the health-disease process. Health should be considered like life, with the capacity to break through standards and institute new standards, thereby placing value on diversity, multiplicity, human beings' creative capacity and heterogeneity of relationships. In this manner, relationships between professionals and children and their families will be strengthened.

 

REFERENCES

1. Puccini RF. A integralidade na atenção à saúde da criança e o ensino de pediatria (tese de livre-docência). São Paulo (SP): UNIFESP-EPM; 2002.         [ Links ]

2. Ribes Pereira MR, Jobim e Souza S. Infância, conhecimento e contemporaneidade. In: Kramer S, Leite MI (org). Infância e produção cultural. Campinas: Papirus, 1998. p:25-42.         [ Links ]

3. Áries P. História social da criança e da família. 2ª. Ed. Rio de Janeiro: LTC - Livros Técnicos e Científicos, 1981.         [ Links ]

4. Kramer S. Por entre as pedras: arma e sonho na escola. 3ª. Ed. São Paulo: Editora Ática, 2002.         [ Links ]

5. Huberman L. A história da riqueza do homem. 21ª edição (revisada). Rio de Janeiro: Editora Guanabara Koogan, 1986        [ Links ]

6. Perroti E. Confinamento cultural, infância e leitura. São Paulo: Summus, 1990.         [ Links ]

7. Instituto Brasileiro de Geografia e Estatística - IBGE. Acesso em 26 de janeiro de 2011. http://www.ibge.gov.br/brasil500/index2.html        [ Links ]

8. Ribeiro D. O povo brasileiro - a formação e o sentido do Brasil. 2ª edição. São Paulo: Companhia das Letras; 2001.         [ Links ]

9. Instituto Brasileiro de Geografia e Estatística - IBGE. Acesso em 26 de janeiro de 2011. http://www.ibge.gov.br/seculoxx/default.shtm        [ Links ]

10. Rangroo V. The evolution of paediatrics from arqueological times to the mid-nineteenth century and the historical influence on present day practice.Acta Paediatrica 2008; 97; 677-83. DOI: 10.1111/j.1651-2227.2008.00741.x        [ Links ]

11. Hochman G. A era do saneamento. 1ª edição. São Paulo: Editora Hucitec; 1998.         [ Links ]

12. Foucault M. Microfísica do Poder. 3ª Ed. Rio de Janeiro: Graal; 1979.         [ Links ]

13. Bonilha LR, Rivorêdo CR. Puericultura: duas concepções distintas. J Pediatr (Rio J) 2005; 81: 7-13. http://dx.doi.org/10.2223/1276          [ Links ]

14. Novaes HMD. A puericultura em questão (tese de mestrado). São Paulo (SP): USP; 1979.         [ Links ]

15. Freire MMDL. Vidas desperdiçadas: a puericultura no discurso da OMS (tese de mestrado). Rio de Janeiro (RJ): Instituto Fernandes Figueira, Fundação Oswaldo Cruz; 1991.         [ Links ]

16. Blank D. A puericultura hoje: um enfoque apoiado em evidências. J Pediatr (Rio J) 2003; 79 (supl.1): S13-S22.http://dx.doi.org/10.1590/S0021-75572003000700003          [ Links ]

17. Rocha JM. Introdução à história da puericultura e pediatria no Brasil. In: Aguiar A, Martins RM. História da Pediatria Brasileira. Coletânea de textos e depoimentos. Sociedade Brasileira de Pediatria. Rio de Janeiro: Reproarte Gráfica e Editora Ltda; 1996.p. 85-123.         [ Links ]

18. Carneiro G. Um compromisso com a esperança - História da Sociedade Brasileira de Pediatria: 1910-2000. Rio de Janeiro: Editora Expressão e Cultura; 000.         [ Links ]

19. Singer P, Campos O, Oliveira EM. Prevenir e curar: o controle social através dos serviços de saúde. 2ª edição. Rio de Janeiro: Editora Forense-Universitária; 1981.         [ Links ]

20. Pereira AR. A criança no Estado Novo: uma leitura de longa duração. Revista Brasileira de História 1999;19:165-98. http://dx.doi.org/10.1590/S0102-01881999000200008          [ Links ]

21. Braga JCS, Paula SG. Saúde e Previdência: estudos de política social. São Paulo: CEBES/Hucitec; 1981.         [ Links ]

22. Brasil. V Conferência Nacional de Saúde. Programa Nacional de Saúde materno-infantil. Brasília (DF), 1975b.         [ Links ]

23. OMS - Organização Mundial de Saúde. Atenção Primária à Saúde. Alma-Ata (1978). Genebra, 1978.         [ Links ]

24. Brasil. Constituição Federal. Seção II - Da Saúde. Brasília (DF), 1988.         [ Links ]

25. Brasil. Presidência da República. Estatuto da Criança e do Adolescente. Lei nº 8069/90. Brasília (DF), em 12 de outubro de 1990.         [ Links ]

26. Soares JCRS, Camargo Junior KR. A autonomia do paciente no processo terapêutico como valor para a saúde. Interface- Comunic, Saúde, Educ 2007; 11; 65-78. http://dx.doi.org/10.1590/S1414-32832007000100007          [ Links ]

27. Puccini PT, Cecílio LCO. A humanização dos serviços e o direito à saúde. Cad Saúde Pública 2004; 20:1342-53. http://dx.doi.org/10.1590/S0102-311X2004000500029          [ Links ]

28. Conselho Federal de Medicina. Resolução 1931/CFM. Publicada no D.O.U. em 24 de setembro de 2009, Seção I, p. 90.         [ Links ]

29. Estado de São Paulo. Lei nº10.241. Dispõe sobre os direitos dos usuários dos serviços e das ações de saúde no Estado. São Paulo, em 17 de março de 1999.         [ Links ]

 

 

Corresponding author:
rosanapuccini@gmail.com

Manuscript submitted Jun 10 2011
Accepted for publication Mar 05 2012.